Women Prefer Office Procedure during treatment of Early Pregnancy

Most women who undergo surgery following an early pregnancy
failure are often treated in an operating room, mostly under general
anesthesia. However a new study has raised questions about whether women
prefer that approach.

Early pregnancy failure - or EPF - occurs in 14 to 19 percent of recognized
pregnancies. Cases treated with surgery typically haven't been performed in
an office-based setting, even while many other procedures have moved from
the OR to the office. Now, a study from the University of Michigan Health
System suggests that many women would choose the option of having the
procedure done in the relative privacy of an office, without general
anesthesia.

"We found that managing an early pregnancy failure in the office is an
acceptable option for many women," says Vanessa K. Dalton, M.D., MPH, lead
author of the study, which appeared recently in the journal Obstetrics &
Gynecology. "This is a real shift in the way we can approach the care of
women with EPF. Many other procedures have moved from the operating room
into an ambulatory setting, but for the most part, the management of EPF has
not.

"This is a difficult experience for women, and we want to make sure that we
are offering them the type of care that works best for them and which they
prefer," Dalton says.

Studies indicate that sharp curettage (scraping) and general anesthesia are
still common when performing this procedure in the operating room - despite
evidence associating them with higher complication rates than suction
removal without general anesthesia, says Dalton, assistant professor of
obstetrics and gynecology at the U-M Medical School.

The study also found:
Costs were more than twice as much in the operating room compared to the
office procedures, and the procedure was 80 percent longer. Physician
reimbursement did not differ between the two groups.

While the study did not demonstrate that office-based procedures are safer
than traditional operating room management, the authors said they are
concerned about the four-fold increase in bleeding-related complications in
the operating room group in this study. The most likely explanation for this
finding was that all but one of the operating room procedures were done
under general anesthesia, which may contribute to increased blood loss.

Patients opting to have the office procedure reported expecting higher
levels of pain than those going to the operating room, and as anticipated,
they reported higher pain scores.

There were no major complications in either group. Further, no office
procedure was moved to the operating room or converted to general anesthesia
for patient discomfort.

Those enrolled in the study were women 18 and older who came to the U-M
Department of Obstetrics and Gynecology for surgical management of a
first-trimester early pregnancy. In all, 165 women enrolled in the study,
including 115 in the office group and 50 who chose the operating room.

Participants completed a self-administered questionnaire at the time of
enrollment. Immediately before discharge, they completed a second
questionnaire addressing pain, bleeding and satisfaction with care.

The findings "dispute the notion that current practices are based on patient
preferences," Dalton says. "Overall, our institution's experience has been
that about half of women choose to have their procedures completed in the
office. In the study group, only 25 percent of study participants reported
that being asleep for the procedure was highly important. Instead, many
participants opted for an office procedure that better meets other needs
such as privacy and efficiency.

"It is important that we pay attention to their wishes and offer the
services that best meet their needs," she says.

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